NMAT
National Medical Admission Test
IDENTIFICATION (ID) FORM
(Must be SUBMITTED to the Examiner on the day of the test)
Application No.: 1031708729
DONNA MAE LAZO DOMINNO
Bank Reference No.: 1841834325
Name of Applicant (name that will appear on your Answer Sheets and Examinee Report Form)
1995-12-03 Female Philippines Single
Birthdate Sex Nationality Civil Status
Saint Louis University, Baguio City, Benguet
Name of College Graduating From
Benguet Philippines
2 X 2 ID Picture
State/Province of College Graduating From Country of College Graduating From
BS in Pharmacy 2016-2017
College Course (Bachelors Degree) School Year Graduating
contact information
#34, Tagudin, Ilocos Sur 2714 Philippines
Home Address
Test Center: Manila
2-01 ABUAN APARTMENT NEW LUCBAN EXTENSION ROAD, Baguio City, Benguet 2600 Philippines
Test Date: March 26, 2017
Mailing Address
Results to be: Sent via postal mail
+63-0742442731 +63-9053889829 [email protected]
Test results and NMAT ID information released
to requesting medical schools? Yes Landline Mobile E-mail
(For Foreign Applicant only)
Medical School Choices:
1. St. Louis University - College of Medicine
2. University of the East - Ramon Magsaysay Memorial Medical Center Passport No Expiry Date Place of Issue
3. Centro Escolar University - College of Medicine
FOR THE NMAT APPLICANT
1. Bring this Form to your school. Your School Head must affix his/her signature on the space provided below to certify that you can graduate by the end of the
school year stated above.
2. Bring this Form to the nearest Bank of the Philippine Islands (BPI) branch and pay the total of NMAT Registration and Test Fees (PhP________)
PHP1900.00 on or before
___________________
March 03, 2017 (Philippine Standard Time).
Copy the Bank Reference No. found on the upper left portion of this Form and CEM’s BPI account number 1881-0450-24 on the BPI Payment/
Deposit Slip. BPI may collect PhP30.00 - PhP50.00 as additional service charge.
3. Check your email (including your spam mailbox) after two (2) business days for your payment confirmation email. You may also visit the NMAT website to verify
the status of your NMAT application and to download the NMAT Practice Set after payment has been confirmed.
4. Visit the NMAT website two weeks before the test date to know your room assignment and to download your Examination Permit.
5. Affix your signature on the certification below:
I hereby certify that I have read, fully understood, and accepted all the information, terms and conditions specified on the NMAT Bulletin of Information and on
the NMAT website www.cem-inc.org.ph/nmat, including, among others, the NMAT policies on refund of test fees, on cheating or improper test-taking behavior in
any manner or form, and on failure to take or complete the test on the test date and test center indicated on this Form. I further certify that all information I gave
on this Form is true and correct to the best of my knowledge and that any misinformation shall constitute grounds for my disqualification from taking the NMAT
or invalidation of my NMAT results.
Applicant’s Signature Date Signed
FOR THE SCHOOL HEAD
Please affix your signature on the space provided below to confirm the identity and academic status of the NMAT applicant.
I hereby certify that the person in the picture above can graduate from ________________________________________________________________
Saint Louis University, Baguio City, Benguet
with a college (bachelors) degree of/in ____________________________________________________________
BS in Pharmacy by the end of school year ______________.
2016-2017
He/She can apply for admission to any Philippine medical college in the next schoolyear ________________.
2017-2018
Signature & Printed Name of School Head Designation Date Signed
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